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Transcript of New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright...
![Page 1: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/1.jpg)
New and Old Problems with Anesthesia Equipment
BWH Anesthesia Grand RoundsJuly 9, 2003
© Copyright 2002-2003, James H Philip, All rights reserved.
![Page 2: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/2.jpg)
Equip Probs JHP Ready
![Page 3: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/3.jpg)
If you stay you will learn how and why the following are true
Suction can fail 11 different ways
There are many ways a vaporizer can fail
O-rings cause many failures
New Tec7 vaporizer needs special filler adapter and must be pressed to fill
Checkout includes Ventilator
Checkout includes “Admit Patient” to reset alarms
Use an HME to keep the circuit dry and ventilator and gas sampling working
Gas Sample Filters are cracking. Save all that crack to be sent to Manufacturer
Free-hosing with Forced Hot Air (e.g., Bair Hugger) is dangerous - don’t do it
Draeger Fabius moos and can have negative (sucking) leaks
A shorter checkout is possible - Should we post it? Should we do it?
ECG Filter must not be set to Maximum if want to monitor S-T, T waves
Problem Solving - Clinical vs Technical; Treat signs; Find & Treat Root Cause
![Page 4: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/4.jpg)
Block on:Problem Solving in Anesthesia
July 9, 20037 - 8 AM New & Old Problems with Anesthesia Equipment
James Philip, M.D.8 - 9 AM Hypotension
George Topulos, M.D.
![Page 5: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/5.jpg)
New and Old Problems with Anesthesia Equipment
James H. Philip MEE MD CCEAnesthesiologist
Medical Liaison for Partners Biomedical EngineeringDirector of Technology Assessment for BWH
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Biomed Intro
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Failed Suction
Patient is a 29 yo F receiving general anesthesia for elective gynecologic surgery.
Immediately after loss of consciousness, the patient vomits
You place the Yankauer Suction in patient’s mouth and occlude the vent hole
But, nothing happens
What is going on?
![Page 8: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/8.jpg)
Suction can fail in many ways
DISS (Diameter Index Safety System) Connector Unscrewed at Wall
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Suction can fail in many ways
DISS (Diameter Index Safety System) Connector Unscrewed at Wall
Vacuum Switched Off at DISS Connector
![Page 10: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/10.jpg)
Canister problem
Hose disconnect from canister
Canister switched off
Insert seated incorrectly
Any port or hole open
Hose disconnect from holder
Tubing disconnect from canister
Flap valve closed
Canister Tilted
Canister Full
Hose kinked
![Page 11: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/11.jpg)
Suction Solution
Test Function
Before Case
During Case
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New Vaporizers have New Failure Modes
![Page 13: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/13.jpg)
Tec7 Vaporizer by Datex-Ohmeda
Differences from previous
White, not blackStill Agent-specific for: Halothane, Enflurane, Isoflurane, Sevoflurane
Wider flow range = .2 L - 15 LPM
Non-spill system limits movement of liquid if tilted or inverted
No periodic service required ( Tec 4 = 1 yr, Tec 5 = 3 yr, Tec 7 no)
Easy-fil™ System50% faster fill than previous (Tec 3,4,5)Low-leak fillIntuitive alignment (they say)Soldered sump and seal (not O-rings)
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Easy Fil™
No Spill
Auto Fill ?
Press toovercome
springNo
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Which is filling as we watch?
Desflurane Tec6Semi-Automatic Fill(no patent pending)
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Why no O-rings?
O-rings fail
Space Shuttle
Forreger Anesthesia MachinesO-Rings sealed a three-vaporizer turretFailed during drug administrationSimultaneous delivery of multiple overdosesLast product Forreger ever made
Desflurane bottle fill
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The O Ringbelongs here
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The O-Ringis missing
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This is filling with no O-ring
![Page 20: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/20.jpg)
When you change a vaporizer
![Page 21: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/21.jpg)
When you change a vaporizer
You are expected to do a
Negative Pressure Leak Test
[See FDA Pre-Use Check Card attached to every Anesthesia Machine]
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NegativePressureLeakTest
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NegativePressureBulbis inDrawer
If not,Page yourAnes Tech
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Condensed water vapor
Makes Ventilators fail
Makes Gas Monitors fail
Use a Heat and Moisture Exchanger
![Page 25: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/25.jpg)
Wet dome valve - Ohmeda Mod 2
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Wet dome valve - Aestiva
![Page 27: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/27.jpg)
Fabius flow sensor gets wet, too
![Page 28: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/28.jpg)
Wet ET tube, dry circuit
![Page 29: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/29.jpg)
Datex-Ohmeda Edith® is BWH present HME product
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Gas Line Filters sometimes crack
Save them if they do crack
Page Anes Technician who will bring it to ORCSS Materials Management”
to return to ManufacturerFor analysis
![Page 31: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/31.jpg)
Forced Hot Air warming
Use a Blanket
Do not use hose without Blanket
FDA, ECRI, Manufacturers are appropriately concerned
Blanket costs around $10.00
This is not the right place to save money
![Page 32: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/32.jpg)
Fabius idiosynchrocies
Moos like CowTemporary problem which will be solved
If reservoir bag is empty or has a leakAir will be drawn into breathing circuitduring mechanical ventilation
![Page 33: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/33.jpg)
Anesthesia Machine Checkout
Important
Will pick up many problems
Common root cause of mishap is:
Failure to Pre-Check Equipment
![Page 34: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/34.jpg)
Check Ventilator Functionas part of Check Out
Ventilate reservoir bag
Observe no volume loss
Added recently to
our list
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Admit “New Patient” or re-bootMonitor and Ventilator
Returns alarms and configuration
to Site-Standard Settings (BWH)
Failure to do this has led toseveral reported “events”
Added recently to
our list
![Page 36: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/36.jpg)
Placard on every Anes Machine
Should we also post abbreviated checkout?
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AbbreviatedMachine Check Out
Calibrate Oxygen Monitor
Check Machine for gas delivery
Check Circuit for integrity
Check Ventilator for function
Check Exhaust for function
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ECG Monitor filter must not be set to Maximum
Monitor offers several bandwidth options
All faithfully convey ST and T waves except
Maximum Filter
This keeps wave on screen but
Distorts S-T segment and T waves
ST and T are “low frequency”
“Maximum” filter removes (ruins) these
Bandwidth Definitions
Diagnostic = .05 - 120 Hz
Monitoring = .05 - 40 Hz
Moderate = .05 - 25 Hz
Maximum = .5 - 25 Hz - the only really bad one
![Page 39: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/39.jpg)
Troubleshooting a “Clinical” Problem
Phase 1 – Patient or Equipment Problem ?
This differentiation is crucial
Starting on the wrong track is a bad start
Phase 2 – Treat Signs and seek Root Cause
Phase 3 – Treat or correct Root Cause
![Page 40: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/40.jpg)
Thank you
![Page 41: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/41.jpg)
![Page 42: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/42.jpg)
If you stayed you learned how and why the following are true
Suction can fail 11 different ways
There are many ways a vaporizer can fail
O-rings cause many failures
New Tec7 vaporizer needs special filler adapter and must be pressed to fill
Checkout includes Ventilator
Checkout includes “Admit Patient” to reset alarms
Use an HME to keep the circuit dry and ventilator and gas sampling working
Gas Sample Filters are cracking. Save all that crack to be sent to Manufacturer
Free-hosing with Forced Hot Air (e.g., Bair Hugger) is dangerous - don’t do it
Draeger Fabius moos and can have negative (sucking) leaks
A shorter checkout is possible - Should we post it? Should we do it?
ECG Filter must not be set to Maximum if want to monitor S-T, T waves
Problem Solving - Clinical vs Technical; Treat signs; Find & Treat Root Cause
![Page 43: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/43.jpg)
Requests from Anes Dept
Negative Pressure tester in each room
Techs do the negative pressure test when they change Vap
Techs do circuit pressure test when they connect circuit
Aquanaut in OR where used - likely Anes Machine Drawer
5% Sevo alarm default on RGM - Increase it if possible
![Page 44: New and Old Problems with Anesthesia Equipment BWH Anesthesia Grand Rounds July 9, 2003 © Copyright 2002-2003, James H Philip, All rights reserved.](https://reader035.fdocuments.in/reader035/viewer/2022062511/5517fb7d55034693228b4a06/html5/thumbnails/44.jpg)
End Here
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New Resources - on Anes Server or CD
From Anesthesia Clinical Bioengineering Elective Residents
Brain Monitor Physiometrix PSA4000 - Maurizio Albala MD
Brain Monitor Aspect BIS - Maurizio Albala MD
GE (Marquette) 9500 Monitor - John Cabral MD
Ohmeda RGM Monitor - Jason Ryan MD
Ohmeda Tec5 Vaporizer in pieces at Sea Level & Altitude Jason Ryan MD
Aestiva Check-Out - Morana Lasic MD
Ventilators - Sascha Beutler MD
Respiratory Mechanics Module - Eveline Ehrl MD
Gas Sampling systems - Jasline Dhingra MD
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End
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Whom to AskJames H. Philip, MEE, MDAnesthesiologist andDirector of Bioengineering (Anesthesia)Office
PBBH - B Ground732-7330 BB1615)[email protected]
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End